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The purpose of this study was to use a low-cost method of estimating prevalence of diabetes mellitus for a small island population receiving medical care from a single facility. A suitable sample of 692 (16.4%) from a total of 4,223 medical records of Ebeye Island Marshallese adult outpatients 30 or more years of age was reviewed in July and August 2000 for evidence of diabetes mellitus. Diagnosed diabetes was defined as having a diagnosis of diabetes noted in the chart. In patients without a diagnosis of diabetes, undiagnosed diabetes was defined as one fasting whole blood glucose > or = 70 mmol/l (126 mg/dl) or one random whole blood glucose > or = 11.1 mmol/l (200 mg/dl). Impaired fasting glucose was defined as one fasting whole blood glucose 6.1-7.0 mmol/l (110-125 mg/dl). For this population of adults 30 or more years in age, the crude prevalence of diabetes [diagnosed cases 13% (confidence interval, CI = 10-15%) and undiagnosed cases 6.9% (CI = 5.0-8.8%)] was 20% (CI = 17-23%). As the population of Ebeye is younger than the world population, adjustment to a standard world population gives an age-adjusted prevalence of diabetes in adults 30 or more years of age of 27%, and an age-adjusted prevalence in adults 20 or more years of age of 20%. In comparison, the crude prevalence of diagnosed and undiagnosed diabetes in the U.S. in adults 20 or more years of age is 8.3%, and the worldwide prevalence in adults 20 or more years of age is 4.0%. Limitations of our methodology include lack of randomization, lack of access to proper laboratory equipment, and passive case-finding, necessitating revision of standard diagnostic criteria. Prevalence rates of diabetes in Marshallese outpatients are thus significantly higher than US or worldwide rates. In addition, there are many cases of undiagnosed diabetes in the RMI. Recommended are a cross-sectional serosurvey of a large age- and gender-stratified population, increased resources to care for people with diabetes, and public health interventions to improve nutrition and facilitate physical activity in order to lower the prevalence of diabetes. The large-scale social forces that lead to diabetes need to be addressed accordingly.